Culturally compelling strategies for behaviour change: A social ecology model and case study in malaria prevention

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Abstract

Behaviour change is notoriously difficult to initiate and sustain, and the reasons why efforts to promote healthy behaviours fail are coming under increasing scrutiny. To be successful, health interventions should build on existing practices, skills and priorities, recognise the constraints on human behaviour, and either feature community mobilisation or target those most receptive to change. Furthermore, interventions should strive to be culturally compelling, not merely culturally appropriate: they must engage local communities and nestle within social and ecological landscapes. In this paper, we propose a social ecology perspective to make explicit the links between intention to change, actual behaviour change, and subsequent health impact, as relating to both theory-based models and practical strategies for triggering behaviour change. A social ecology model focuses attention on the contexts of behaviour when designing, implementing or critically evaluating interventions. As a case study, we reflect on a community-directed intervention in rural Gambia designed to reduce malaria by promoting a relatively simple and low-cost behaviour: repairing holes in mosquito bednets. In phase 1, contextual information on bednet usage, transactions and repairs (the ‘social lives’ of nets) was documented. In phase 2 (intervention), songs were composed and posters displayed by community members to encourage repairs, creating a sense of ownership and a compelling medium for the transmission of health messages. In phase 3 (evaluation), qualitative and quantitative data showed that household responses were particularly rapid and extensive, with significant increase in bednet repairs (p<0.001), despite considerable constraints on human agency. We highlight a promising approach—using songs—as a vehicle for change, and present a framework to embed the design, implementation and critical evaluation of interventions within the larger context—or social ecology—of behaviour practices that are the bedrock of health interventions.

Introduction

Effective behaviour change is notoriously difficult to initiate and sustain, even where communities are well informed about simple means of health promotion or harm reduction. This applies to a whole range of behavioural interventions, whether aiming to encourage people to use condoms, give up smoking, increase physical activity and eat more nutritious food, or promote better hygiene, child care and education (Adams & White, 2003; Curtis et al., 2001; Glasgow, Klesges, Dzewaltowski, Bull, & Estabrooks, 2004; Hardeman, Griffin, Johnston, Kinmonth, & Wareham, 2000; Manandhar et al., 2004). Indeed, there are remarkably few examples of truly successful health interventions, where the measure of success is a behaviour change that is acceptable, affordable, effective, sustainable and generalisable.

Major health interventions have been successful, even in places of grinding poverty and weak health systems, where there has been top-level political and financial commitment, delivering technological innovations at the right price, to produce significant health gains (Levine, 2004). While this is an important lesson learnt, the key reasons underlying failures and successes in promoting community-wide behaviour and lasting health impact are still under scrutiny. In reflecting upon ‘best practices’ in the developing world, Higginbotham, Briceno-Leon, and Johnson (2001) presented the 12 best cases of health intervention known to them, contextualising the reasons or ingredients for success in the communities concerned. One noteworthy conclusion was that community mobilisation had to feature a culturally compelling package for the design of the health intervention, not merely a message designed to be culturally appropriate. It is the ‘compelling’ element of the intervention that will mobilise communities wholesale, rather than effecting behaviour change in piece-meal fashion with the hope of trickle-down or trickle-up effects. This insight helps address the crux of disappointment in many health interventions, namely gaps between the awareness of risk, the intention to change behaviour and actual behaviour change.

In search of a better understanding of the determinants of behaviour change, a number of theoretical models have been proposed, expanding the original emphasis on salient health beliefs (as in the health belief model, HBM) to highlight the social, economic and cognitive processes that shape beliefs and encourage or hinder behaviour change. In health education, frameworks such as knowledge, attitude, belief, practice (KABP) or belief, attitude, subjective norm and enabling factor (BASNEF) are commonly used (Hubley, 1993). For their part, social cognitive models have focused attention on the intention to change and self-efficacy (theory of reasoned action, TRA; theory of planned behaviour, TRP; Abraham, Sheeran, & Orbell, 1998). In stage-based approaches (transtheoretical model, TTM), messages are tailored to individuals at different stages of readiness for change (Adams & White, 2003; Malotte et al., 2000; Riemsma et al., 2002) rather than to communities as a whole. It is also now widely recognised that to be successful, interventions should build upon existing local practices, target those community members most receptive to given health messages, bolster local skills and priorities, recognise time, economic, cognitive and social constraints on human agency, and feature mobilisation of the community (Table 1).

Drawing upon such insights, we focus this paper on critical distinctions between a culturally appropriate, a culturally compelling, and a culturally effective intervention in the quest to achieve public health impact. We propose a model taking explicit account of the social ecology of health-related behaviours and triggers for change (addressing why and how people mobilise), as informed by an intervention study for malarial prevention piloted in The Gambia.

Section snippets

A social ecology model (SEM) of behaviour change

Existing literature reviews have argued that well-designed and targeted interventions are more likely to be effective if they are theory based—namely, if they draw upon a theoretical underpinning of the established determinants of behaviour and behaviour change (Fishbein, 2000). They should also present satisfactory evidence regarding the links between psychosocial or behavioural change and actual health impact (Curtis et al., 2001; Glasgow et al., 2004). Thus, successful interventions might

Intervention case study: malaria prevention in The Gambia

We conducted research in The Gambia to explore the feasibility of a community-led intervention designed to reduce malaria by encouraging people to repair damaged bednets. In the tropics, malaria control programmes are based largely around the prompt treatment of clinical cases and the promotion of insecticide-treated nets as a means of reducing exposure to the bites of sporozoite-infected mosquitoes. Yet although usage of mosquito nets is increasing in Africa, many of the nets employed are torn

Methodology: study area and population

We based the research in two neighbouring villages in The Gambia, where usage of bednets and exposure to mosquitoes were high. The Gambia has a long tradition of net use, first documented in 1894 by Mary Kingsley during her travels in West Africa (Aikins et al., 1993). Even today The Gambia has one of the highest rates of net use in Africa (WHO & UNICEF, 2003), although few nets are treated with insecticide. Nonetheless, the frequency of bednet use varies considerably within the country,

Qualitative and quantitative research appraisal

Our investigation integrated both a qualitative appraisal of household practices and perspectives with quantitative data related to malaria exposure and its prevention. We began with in-depth interviews and focus group discussions with participants categorised by age and gender, to probe views of malaria as a risk to health, understanding of malaria transmission and mosquitoes, local usage and relative value of bednets, and social responsibilities for purchasing nets and maintaining them in

Use of bednets

As expected, use of bednets was high among the two study villages. Of a total 772 beds surveyed, 554 (72%) had a bednet. Nets were usually untreated: less than 1% were reported to have been treated with insecticide. Net use was clearly associated with tradition—referring to use of bednets, a villager stated: “as our grandparents before us, so our children shall continue”. Sleeping arrangements and the sharing of nets were consistent with earlier observations in The Gambia (Aikins et al., 1993;

The intervention (phase 2): song and posters to trigger household mobilisation

Having ascertained that the repair of damaged nets was already established behaviour, it became clear that an intervention aimed at using and maintaining bednets in good condition did not have to primarily focus on beliefs, attitudes, norms and practices (Fig. 1) related to malaria prevention, as these were extant in the communities under observation. What was needed was to find a strategy to augment actual practices into a behaviour change that would have demonstrable health impact: a trigger

Community perspectives

The song and posters were widely appreciated by the communities, who reported that they provided a useful stimulus for repairing nets. Interviews and focus group discussions were run to evaluate the ‘social validity’ of this intervention. While the intermittent presence of a field research team might have encouraged behaviour change, this was not mentioned by the community. What villagers did emphasise was a sense of local ownership, pertaining to the fact that the song had been composed

Reflecting on social ecology

Although our investigation failed to demonstrate a public health impact, the intervention did succeed in contributing to a significant change, in that households took immediate and appropriate action to repair their bednets. This indicates both that it is feasible to promote net repair and that the media of locally composed songs and posters are a promising approach to encourage and augment existing health priorities and behaviour. Most public health interventions stop at examining either

Conclusions

A social ecology model (SEM) was used in our research to make explicit the determinants of behaviour change, the strategy for promoting behaviour change, and the evaluation of the intervention. Fig. 1 helps to focus attention on reasons why changes in beliefs and attitudes does not necessarily lead to behaviour change, while behaviour change does not necessarily lead to an impact on health.

We explored the feasibility of an intervention in a context where behaviour change seemed possible and

Acknowledgements

Research was funded through an award from the Bill and Melinda Gates Foundation to the Gates Malaria Partnership. We thank all study participants and support from the Gambian National Malaria Control Programme and the Centre for Innovation against Malaria.

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